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Yeah. Hello, everyone. And welcome to the weekly minded BLEEP Webinars. Welcome to the medical series. And today we're going to talk to you about chest X rays, and we're joined by Dr Laura and Doctor Wendy who are going to tell you all about demystifying chest X rays. Um, and please, if you have any questions at all, post them in a comment section and we will try to answer those in the end during the Q and A session. And if you haven't had any questions after after the webinar, please feel free to to get in touch with us via Facebook or via mindedly website. Um, the session is going to be recorded, and at the end, we're going to post a feedback link. After you fill in the feedback form, which we will really appreciate. We're going to make the recording materials available to you and you can access them at any time. And if you want to sign up for the future Webinars, I'm going to post a link in the comment section in a second. Um, so without further for Daddy, I'm just going to hand over to Dr Laura T delivering session. Really? and thank you very much dot Good evening, everyone. Thank you for joining. So yes, I'm a radiology regimen over livable. And I was asked to do this session. I think it's actually a really good idea because they are, like, everyone thinks they can look at a chest X ray, but then when you start learning, probably start like, you know, training about actually realize how difficult they are. So I thought we'll go right ship it right back to basics, because that really does help. So I think that is what we should do. So we can start now. Um, so, yeah, we'll just get a chest X rays today. We'll just not letting me. Okay, so first of all, I thought, What do you guys want to get out of the session of anything specifically like, What else are you proposing? The comments. That would be brilliant. Um, I know when he's going to keep an eye on the comments for me, and then she will interrupt me at any point. If anyone asks anything or anything like that, if it's something really specific to, like an image, then you know, Post. And when it stopped me And if it's something general, then we can see at the end. Okay, so I kind of looked at these, so I thought, how to generate an X ray? It's certainly something we have to learn as registrars for our exams, but I don't really recall much about it in medical school at all. Um so I thought maybe we could look at that real quickly. The key to radiology and any imaging interpretation is normal anatomy. You don't know what's abnormal. So you know what's normal? Sounds stupid. But believe me, when you're looking at a two D picture of the three D object, things can get a little bit difficult. How to approach a plain film. X rays of plain films, interchangeable words. So remember when I was doing more brands and things when I was a lot, You know, when I was a lot more junior, remember thinking, Oh my gosh, when people ask me to interpret test section award around in front of the consultants, the nurses, the Reg is their forms of tears. I just used to freak out, so I thought, I'll show you how to do it so no one has that freak out situation. General principles of image interpretation is really important that you can use that to any imaging reality at all. I like I do an A B C D E. Approach. You can have whatever approach you like, as long as you stick with it. That's the main thing you've got. You've got to be quite rigid. And then the review areas. Every imaging modality has a review area. It's where we miss things where pathology can hide. Okay, so that's what I thought. Anything you want to add? A Pop it in the comments. How do we get one? How do we get an X ray? We just want an X ray. We get it like that don't mean how do we make one? So this is kind of pretty much most X ray images machines, So the patient stands in front of the detector. So there's a film inside the square just in front of the patient that that captures the image. They used to be physical films like pieces of paper like pieces of a photograph of paper. Almost now they're all digital, and then the little small aperture behind the patient, and you can see the little smaller square that is the X ray beam. That's where the actual X rays come from. The radioactive material. All that stuff is all within that square. Okay, we prefer the patients to be standing this way. I'll explain that to you in a second. Obviously, as I'm sure you've seen, when patients are very sick overnight or the end of the day or the too sick to stand up like that, then we can do it with the way around. So we'll go through that as well. So within the little square behind the patient, this is going on. So this is the X ray, too. Okay, so the there's a there's a positive side. The negative side, remember, an X ray is generated by a very, very, very high charged beam of electrons. As you can remember from your levels, as long as they might have been a while ago, we still got to remember them. And they are negatively charged particles. Okay, they are negatively charged particles and the little curly thing on the left hand side of the image that is a filament. So we apply a really high electric bolt through the filament to release a load of electrons, so they're all sitting there negatively charged together. We then apply a current across the whole X ray tube to accelerate the electrons towards the orange thing. Orange thing is called the target that's made out of metal, basically like tungsten. Usually we use and hitting the and when the electrons hit the target X rays and release basically and that is how you making it. That's how you get an X ray. They then come. They are directed downwards or any direction. Really, however, your tubes facing, usually it's downwards toward your patient, and then the X rays go through the patient and they're absorbed. So different structures in the body, different tissues. So bones, lungs, soft tissues, muscles. They all absorb different amounts of X rays, and then that is then projected onto the film in front of the patient. The picture of them. Ideally, you want the patient to hold the film, and they literally cuddle the film that moves the shoulder blades out of the way so we can fire as many electrons and as many X rays. Sorry, through the lungs as possible, and that is how you make an X ray in a very quick basic way, so it's not protected Very well. Sorry, but yeah, basically, X rays are all black and white. Gray scale, um, unfortunate. And in my life is not black and white, and so black is air. So X rays go straight through where they're not attenuated because they're absorbed by air. They go straight through. So they they look black. That absorbs a little bit more, so it absorbs bit. So you get like a dark gray color light gray, soft tissue. It's hard to tell it could be muscle could be ligament. It's difficult to tell, really. Pretty White is going to be bone. So in a chest X ray, for instance, very, very white is going to be bone, you know, like a skeleton. And then, if it's extremely white, almost blinding compared to the black, it's going to be metal or some something foreign body basically the most. So the most attenuating natural thing is bone. Okay, so that's kind of how we interpret all images. Really? Remember, I said about how the patient should stand in front of the tube so they should basically could cuddle the detector okay. That means that we can get an accurate size of the heart, so we call them P A and AP, So it's posterior material. So the X rays are going from the posterior aspect of the patient to the anterior aspect of the patients, so they're going to write the way through from the back to the front. An AP projection is the opposite way around. That's done. If the patient is on well or they're not very mobile or they're just so, so sick. We need a picture whether it be a good, good quality of our quality, really, that means, unfortunately, the heart is closer to the X ray tube, and the way X rays work is they go. They come out in a line, they diverge. So that means in an AP projection, we can't tell how big the heart is. It can look massive and actually be normal. And it's all it's all to do with an artifact of the X ray production. Basically, so you have to take that with a pinch of salt. Every X ray should have on it a side market because, you know, normally we can tell what's the left and what's the right because of where the heart is? Well, sometimes people's hearts on the wrong side dextrocardia. So we often will always have to put aside marker on. And they will always tell you what projection the film is in as well, whether it's a pa or an 80. Okay, I'm going to show you some samples now. So this is on the left hand side of the screen is a pa that is a normal chest. That's what we want. We want a normal pa. So this one, as you can see the patient, is you can see all along beautifully. The nice and a rated the scapula way out of the way. You can't They're not really projecting through the hemithorax at all, and the heart is a nice normal size. On the AP film, you can't really see all the lungs properly because the scapula in the way and we're also looking at the heart. It looks absolutely ginormous, and I bet you it's normal, to be honest, but it looks massive because of the divergence of the X rays. It creates a bigger shadow to bear that in mind when you're looking at a chest X rays always have a little look if it's PA or 80 normal anatomy. Unfortunately, I can't go through. All the screening tests will be here for next week, but the important things to look out for an X rays, particularly on chest X rays. Um, we call it the silhouette sign. So in order for us to see what's going on inside the body with X rays, we need we need a contrast. So we need a difference in tissue density between two objects, so we use the normal anatomy to compare. So, for instance, we look at the left ventricle wall there. It's really nice. It's really nice and delineated. It's a nice, big, thick muscle with blood inside it, and it's sitting in front of an aerated lungs. That's how we can see where the heart is compared to lungs. If someone's got a chest infection, I've got some consolidation in the left. The left lingular That's the left lobe that covers that covers the left ventricle that we lose that nice, crisp look. Nice crisp line between the higher density heart and the low density lungs. So things are like like say, normal and and actually very important stuff like that. So if we go down the center, can you see my hope? You can see my, um what do you call it? My cursor. And if not, apologize but the center of the screen center the image. Sorry. We can see the trachea, the windpipe going down there, and then you can see the bifurcation of the bifurcation when was called the Carina. Um, the right main bronchus is more vertical, and it's slightly shorter than the left name brand because the left main bronchus kind of sweeps up a little bit. We can see the aortic knuckles. That's where the arch arch is down, arches around on itself and comes down. That's a very important anatomical landmark landmark for us sticking into technology. And then we see the pulmonary trunk coming through on the left hand side, just kind of just near where that left main bronchus is coming off in between the aortic knuckle and the pulmonary trunk is called the AP window. Now that's quite I remember. It was in my finals. Actually remember a question on this. If there's something obscuring the AP window, it's usually highly lymphadenopathy, so that's a little nugget you can kind of remember. So that is where it should be. You should see a nice aortic pump and then a pump on your trunk bump. You shouldn't see anything that shouldn't be rounded. Basically, it should be like like this. Like like a backwards three almost. Um, obviously, you got your left hand on your left side of the heart. There. You've got your right side of the heart on the other side. You've got pulmonary arteries coming on the right and the left hand side. You can see the spinous processes quite well on this one. In the paratracheal strike, we look for quite a lot, actually, to indicate pathology and the anti the mediastinum and the paraspinal line. To be honest, I cover off the top of my head. What pathology that is Basically normal anatomy is quite important. Okay. Obviously you got the ribs. You got the clavicle. Um, I've got the spine, the Spanish head circles as well. You know, the little round things you can see on each side of the vertebral bodies. Okay, so just absolutely beautiful chest X ray. I want to show you It's probably a nice one I've seen. I wanted just to show you. If you look at the clavicles and look above each clavicle, it looks like they're almost two bones there. There's two shadows really forgot to tell. What is the edge of the clavicle? And what is this weird shadow? What is it? They got four clavicles now that is called a companion shadow. Very common. We see it all the time. It's to do with the X ray production, but it's extremely common. And don't it's kind of thing that, um, more senior like Reg or a consultant will say to you, What's this? And you go, you can say, Oh, it's a companion shadow. I think they'll probably follow. That's a dentist, But yeah, that's what that is. I wanted to show you as well. The spinous processes down the center of the spine are absolutely beautiful. If you look at the left main bronchus, you can see you're arching very nice, and you can also see the pulmonary arteries and heart vessels. And on the right hand side, it's slightly more difficult to make out, and you can see the right main. Bronchus is more vertical, and it's short in the left. You've got your hemidiaphragm. So each side of the diaphragm is a hemidiaphragm. You've got a beautiful what we call costophrenic angle cost avian ribs, phrenic diaphragm. We look down here for fluid. So infusions or hemothorax, anything like that. And we have the cost. Oh, no. The cardio phrenic angle, which is the angle between the heart and the diet. Okay, so, really, the United States that you're probably not going to get better on that ever now interpretation. Thank God we don't need to look at the films like this anymore, because I know they're really hard Plain chest X rays. This is the kind of thing I want you to think about. When you asked to say when someone says to you, What does that chest X ray show? Don't just jump in and go? Oh, consolidation. Because it's just such an easy thing to get your head into. First of all patient details, every X ray should have the patient details on the top left on the top. Right. So just say this is a plane chest X ray of Fred blogs, 52 year old man. Okay, the date and time of the examination well beyond there. Now that's actually quite important. It sounds really silly, but it's really important, because if someone shows you the chest X ray from literally the middle of the night, it's probably because he's sick. Like who gets around, You know you're not going to get a GP. Refer a patient for an X ray for a chronic cough and the tone up at three o'clock in the morning. That's not going to happen, is it? So you know, you look at the time, Is it? Is it three o'clock on a Friday, or is it three o'clock in the morning on a Saturday? If it's Saturday, they're probably sick as part of the part of our assessment, where we sea sick, patient as a chest X ray. As a rule, I always do. And when I see a patient because 9 lbs out of 10 will be something on the chest, um, any previous imaging? My heart sinks when I opened a scan, and there's no previous imaging. Unfortunately, it really helps us see there's so much going on there. Like I say, it's a two D picture of a three D patient. Things are squished. Things are super imposed. So we look for any comparison. Basically, if something has been there because a little, if there's a little nodule in the lung and it's been there for 10 years and not changed, probably probably benign. So, yeah, then we assess the quality. So again, projection. Is it a P or PA? We want a pa if the film is at three o'clock in the morning, and it's an AP guarantee that patient sick and I guarantee they'll be showing it to you for a reason, probably got something hideous on the chest. Okay. Is it supine or direct? We want an erect chest X ray. We want that patient standing up you to be holding that, getting the scapula out the way, hugging that detector so that we can see as much aerated long as we can. We want them to breathe in nicely. Um, is it a departmental or is it mobile? You know you can't send a patient who's on death's door to the X ray department because it's skeleton staffed. A lot of the radiographers are obviously very well trained, but you know, you've got a lot of sometimes the poor reporters are like We're looking after these patients. If they're too sick, you can't send them down. They can't. You know there's nothing worse than a cardiac arrest in the middle of X ray department and, unfortunately, just happen. So we want, you know, the mobile film probably sick. And also it makes our interpretation more difficult because unfortunately, they're not as good, so exposure. So I'll tell you about exposure. Exposure basically means how much of the X rays of penetrating through the patient. If I get a film, come to me and it's all white. How on earth am I going to make out if there's anything wrong with it? So if it's too bright, not enough X rays of pass through the patients, the filter to the film or the detector? Um, so we need to really increase the exposure factors. If there's if it's all black, it means far too many X rays have gone through. We can't quite delineating some tissues, so you need to. That's not, you know, it's That's a great job for his job. They're brilliant at it. They can eyeball the patient, and they used to say, Well, they're going to need this at the other. So exposure is really important. Rotation is massive. Can't have a home enough. It's a two D picture of a three D objects. So you think about it. If you rotate even a few degrees, the left or the right, and you literally like that, your heart will look huge. Your mediastinum will look huge and it looks pathological. And it's not so Rotation have massive, massive thing. I'll show you about that. An inspiratory effort. Some people, you know, they take a nice deep breath in to really a rate the lungs and, you know, really, really sick. You call it increases the road. We can look at everything, but now that they don't, they take a little tiny breath in and then they exhaled by the time the X rays taken. So it's difficult. So we look for inspiratory effort. But again, if they're really sick, you're not going to get much in spiritual. So exposure factors Do you hate this is got a difference with that? I'm going to say Oh, not God. God. God. Sorry. Uh, this is this is this is this is bad. I can't really make out the lung tissue itself. If there's a cancer in there, I'm not going to see it. Especially if it's down by the periphery. The film. I'm never going to see a small insulin. They're never, never, never, never. We have to report it, but we have to say very poor exposure. Now, what kind of things can contribute to it? Um, like you said things that you can be sick, really sick patients. Um, not breathing properly. This one is not that bad inspiratory effort. Actually, it's not too bad, but they're quite big, aren't they? Now, I'm not the slimmest in the world by by a long shot with this patient so big, and so we need to increase our exposure. Practical patients really, really big. Massive body body habit is we need to increase our exposure practices. Okay, now, this one, What do you think about this one, 71 comment. And when they got any good, bad in between, uh, so far. But usually there's a lag. Keep an eye on it. Okay, cool. So this one is absolutely beautiful. So, exposure wise, we want to be able to see the spinous processes. So they are the pointy bit to the back of the spine. If you feel down, someone's fine. The point of it you can feel, um, it's a little bit a little bit too much down here because I can't quite make them out the hallway down the film. So at the very bottom of the thoracic spine, there is a little bit too much exposure. But as a rule is pretty good now. This patient, you can see she's very dense breasts, so she's probably so. We don't massively radiata. That's probably as good as we're going to get. But we can see the lungs nicely. We can see the bones and chopped off the side here a little bit, but as a rule was, it was very good exposure. Okay, now this one. So there's something really, really not right with this film, so if we start, I've cut off all the patient identification is obviously to have to, but you take one look at this film. First thing that springs to me is it's an 80 so we know it's the wrong way around. So this has been taken this way. It's mobile, so it's been taken on the ward or n I t u r and A and A or the patients too sick to go to the department. And it's erect. Kind of direct. Is it erect, or is it semi erect? Probably semi erect, actually. Probably practice poor fellow off and said, Take a deep breath in, um So yeah, um, they also I check for rotation. So this is an AP film Grant is the heart looks massive, but this is not normal up here, up in the left upper zone. That right upper zone. Sorry, I have left on the right, but it's not good. Is it in the right upper zone? This has been very abnormal. Now is this achiever? What is this? His mediastinum? I think it's mediastinum because if you look at his clavicle so we check the rotation by the clavicles so we look at the end of each particle. So here's the end of the right clavicle. Here's the end of the left clavicle. Now we compare these the spinous processes the spinous processes here. Okay, so it's actually helpfully where this energy tube is wrongfully cited for the record. But here is where the Spanish protesters are, So there should be equal distance between the two ends of radicals. And there's not there's not at all here. The right is on a different, different postcode two left. So probably it's rotational because he's also got some left lower zone consolidation down here. But, you know, I can't say this is a tumor. I can't say it's not a tumor, it makes it very difficult, and I haven't actually slide on this. But if there are any F one to F shoes on this, that's probably more feed. More importantly, really. Remember when I started as a doctor, one of my first job ever was to check a chest X ray for N G tube placement. I've never been taught how to do it, and I nearly had a heart attack. So I remember people saying You can obviously go up and die if they're still in the wrong place. I'll tell you now, quickly, um, the N G tube Sugar Central obviously goes down is not with us, so you should get down to this. I cannot say this is in the right place because I don't think it is actually get some just esophagus. If the tube coils up on itself. So you literally see it go and little coil up at the bottom. That's wrong. That has to be removed. So you have to bring the clinician's and say, Take that off or, you know, you tell the nurses. Take that out. Don't feed to the tube has to go. You have to see it go under the left hemidiaphragm and to the left. Okay, unless it's a judge talks to me or something weird one before. That's different than the normal energy tubes that is far too high. They can't feed through that because it might not be the lungs, but it also might be. So you got Be careful. Okay, remember if it's gone under the left hemidiaphragm and it's sweeping towards the left where the stomach lives. Great to go for it. If not absolutely. It's not worth the risk of know. I've known people misinterpret The patients have been very, very sick, so don't do that. Cool. So check again. Rotation end of clavicles compared to the Spanish processes. Okay, inspiration, expiration. We want them to inspire them. There's big lungs. We can see how much lung tissue is possible. We want it to be stretched out the lungs. I think I read once. If you stretch out, each lung might be lying. But if you stretch out each lung, you can feel a tennis court or something. Maybe it's both lungs together anyway. It's massive, a huge, massive surface area. So we want them to be most areas we can so we can see through them. If they're all squished down, we can't really see much. It just looks difficult. Like if you look on the image on the right hand side, um, like on this left lower zone down here, it almost looks a little bit bunched up, doesn't it? Compared to the one on the left hand side? So I wonder whether actually there's not. Consolidation is just because they're not breathing properly and you can see the difference. You see that in the on the left hand side again, if you look at the the distance between the ribs on the spirit inspiratory films massive compared to the exploratory film. And obviously, if you've got ribs in the way, it's difficult to see the lung tissue underneath because we've got the anterior ribs and the posterior ribs superimposed on the lungs to make it difficult. Okay, So nice. Big, deep breath in snap your shot. Actual assessment of the film. I do a B c d. So I say I look at the airway. I check the breathing for the bones, the bones, the cardiac issue, like the cardiac bits, the diaphragm and everything else you can have your own, I think geeky medics to a similar one. There's so many of them. Some people go in, out, in, out In some people got the most bizarre ways of looking at them. It doesn't matter. You pick yours and you stick with it. And you make sure you look at everything and stick with it. Okay, So everyone okay, basically trachea and Carina, there's not much more you can say, to be honest, uh, like the deviation is it? Push towards something. Is it pulled towards something? Why is it deviated? What's going on? Um, can you see the carina? Usually you can if you look hard enough, sometimes you can't. Um, the right main bronchus should be more versus Like I say, she's more vertical and should be should be a shorter than the left main bronchus that swoops up a little bit. That's why if you've got someone who's inhaled something, probably going to be the right neighborhood, because that's where it goes. I read once about a million years ago, but it's all to do with It's like a pregnancy thing. Um, so it's like a protective mechanism for pregnancy. So if you're going to inhale something, it's going to more likely you are to the right main bronchus and the left main bronchus. Because remember the ABC, all that stuff sits on the left hand side. So if you've got a lady who is heavily pregnant, the branded uterus visitors squishes the I B. C. And it can reduce the venous return. So I think it was something to do with if they're on the, you can take them to the left and you can grab it out the right name brand because I don't know, I read it once. It might be a massive line again. Behave then, uh, the highland as well. I know it's not quite by the airway, but I do look at the Highland. It's right next to the Carina. Um, I'm looking for vascular. Sure, Lymphatics. Basically, we've got massive lymph nodes. It is usually very obvious, and we look at that AP window, which is the three in between the aortic notebook and the pulmonary pulmonary vessels on the left hand side. Okay, so if the trickier is pushed away, there's usually something pushing it. So there's usually going to be a pneumothorax, like on the image on the bottom. So on the right hand side, so the left hand side of the screen that trachea is being pushed the left hand side, the whole mediastinum is being pushed because if you look carefully, that's a max of tension in the thorax because the lung tissue is squished down here. That's all lung tissue. And all this medicine even showed there was the left hand side. That patient needs to be sorted out if we look at the image on the right hand side, Um, this is a massive infusion that's actually pushing the lung the pushing of okay as well. It's not as marked as the other one, but there is some taquitos invasion on there. If you've got a tumor that's really like sticky and pulling everything on the pleural tumor or a lung tumor with pleural attachment, and pull towards the towards the pleura that can pull the trick here towards it as well. So it's just like that. If it's nice and central brilliant, and if it's not, why look at the breathing so we'll have a long term issue. You divide the lungs into three. So we do. Also is the left upper for sorry. The left upper, the right upper mid zones on the lower zones. Okay, there are different numbers of ribs and stuff, but to be honest with, you know, whenever sticks to them, because if you've got someone who's not reading properly or someone who's had surgery doesn't matter. We do it into zones. I literally compare, like for like I look, sometimes you can look at the film, go as normal, and then actually look at it a second time. And you know, there is something there because if you literally split the chest into six, so three right, three left and you compare, like for like quite often you will see something on one side. So that's what I do. And I also looked for my vascular marking, so I've been a bit naughty with so much I just realized it. I want to show you the the the Bronchi. So this is a film. This is called a Bron program, and it's happened by accident. So this has happened because someone's had a barium swallow for esophageal problems and they have inhaled barium, so that is actually oral contrast inside the lungs. But it is a beautiful picture, but unfortunately, patients get really sick. They get really, really sick. So, yeah, I just thought it was a great picture. Wanted to share that because you never see them because it's really bad. So yeah, so we compare both sides, we look at the let me look at the lung marking, so we want to make sure that the pneumothorax some new authorities can be so subtle. It is unbelievable. They are so subtle. Air rises. So you just sit in the hen spikes, one of our review areas, and we look at the lungs at the top Here, you've got rid one coming down with two or three very crowded up. They're very crowded. You've got a tiny little sliver of head in that river. It's going to be really hard to see. You also get a lot of them pleural scarring and pleural backs up here. So pleural calcification. So you get more basically white, more white up here. So how we checked within the thorax as we look at the pulmonary vascular markings so you can miss one is not a great example. You can see the same density is the most you can actually follow. Follow the little lines right to the edge of the lungs. And if you've got another four and it's usually going to be up here or it's going to be huge and then it's usually quite obviously remember if you got an X ray from a patient who's lying down the air would go to the species. The air will stay at the kind of rise to the top of the chest, so they they're very difficult to interpret. We often do a lateral chest X ray as well, so we blast them from the side as well. So we can just see two planes basically and compare. Oh, that's not getting well at all. And I said, Oh, how awful. Basically, this lung is meant to look like a donation. So not only are we looking for, um, no no authorities. We are actually look healthy sometimes. Want to show the parents? Sometimes. You see, I thought like circles. All those tiny, little, little like slightly slightly more black than the rest of the lungs. Match usually down to emphysema. So chronic smoking obviously cause emphysema. Lung damage, parent kind of lung damage. Looks like chronic lung changes on X ray. I'm so sorry. This has come out horribly, but basically, this is the chest sector, like, absolutely full of little rounded, little rounded, Um, uh, areas of high density compared to the lung tissue itself. So I remembering back to our initial slide. And what color is what? I'd be very worried. This is soft tissue. I'd be very worried that this is a horrible, nasty protest going on. If anyone can tell me what these are called, remember impressed. But maybe if Wendy sees any attention and let me know. But I also know that this is called third play. So these are multiple metastases. They're very round. It's a round of multiple lung metastases from a note from from a different cancer. Anyone can tell me I'm very impressed. Okay, so let's look at this. This X ray if anyone wants to write in the chart. But the things going on here, so I'm going to start by splitting the chest into six. Three on the right, three on the left. I'm going to compare the uppers, owns the middle zones and the lower zones, and I am very drawn to this area here. And I think in this area, compared to this area was increased density. That's how we describe things on X rays density. Okay, so that, I think, is a noble consolidation. If you look carefully and you can see here tiny little circles and here tiny, tiny, tiny circles, they are what we call a rep bronchogram. So it's a rare within consolidation. Now, remember, consolidation is like puss and just go inside the lungs themselves. So when you've got the Broncos coming in and Little Airways, this is all I ever Middle Airways. Okay, um, so, yeah, this is this is this is a This is the right middle zone consolidation. Okay, so, yeah, Just look at how bright it is compared to the side. I'll just show you on this. X ray is quite bad. You can see. Hear all these little tiny little little lines. Linear identities. These are all the pollen, the vessels in the normal vasculature. And then you go right to the edge along to go right to the edge. This is a scapula. Careful the scapula that can catch you out. This is the scapula blade here. There's no pneumothorax to be right at the top. What about this film? If anyone can tell me what the things going on here, it's a left side of pathology. I said what? So we divide the lungs. 123. My eyes have been drawn the left, because this looks very, very more dense compared to this. And this looks more dense compared to this On the left, the bottom. Not too bad, actually. Then I look at my lung marking, so I'm trying to trace them right to the edge of the film. On the right, on the right hand side, do Oh, they're all lovely, right to the edge. And then we go to the left hand side trying to trace home the vasculature. It all looks very squished. It doesn't look right. There's no nice lines. And then we stop. This is a this is a very big left side of the thorax. It's not attention, Remember, attention. Pneumothorax is when the air goes in. You can't get out to usually like a penetrating injury. Like a like a blunt trauma with the valve one way valve, the air can get out of the air, can get out and just push, push, push, push, push. And then you get reduced venous return and then based on the product, the rest if you don't compress it quickly. This is not This is a, um not normally the thorax. Um, so yeah. So the reason this is all very congested nothing is because the lungs are literally squished. That's a pneumothorax. So this one, the exposure is not brilliant because it's quite bright. It makes me kind of the wool on our workstations. When we reported X rays, we can actually change the exposure factors, which is quite nice. We can change the windows, We can make them darker. We can help ourselves. Really cheating, isn't it? But if it's there, I'll do it. So I'm gonna access put the chest to three left. The right hand side doesn't look too bad. Actually, this is a bit bulky this highland, but I don't think it's too bad. Then we're going to look at this side. We're going to look at the left hand side now. Upper zone is okay. You might you might You know, I might catch these quite a lot at the top of the lungs. Both sides, this is this is the cost of Chondral Junction. They can be quite calcified. They can look very horrible and sort of like cancer. You've got to get your eye into that because, unfortunately, most of them there are a lot of old people's X rays. Do look a bit junky up here. I'm checking the middle zones. My eyes don't answer that. What is that? So that is good. It's a solitary lung lesion, by the looks of it, very rounded in nature. It's hyper. It's increased entity compared to the lung. And then I see this here. So these are quite bright are compared to the so compared to the bones, these are These are very bright. Remember, looking back to our color chart at the beginning. This is a metallic foreign body. So this is going to be a surgical suture, A clip sorry or staple and behold, I'm no surgeon. This patient clearly had some surgery here, and I think this is a resulting metastases or resulting new tumor or regrowth. Okay, this is the fissure you can see along here. Remember, the right side of the lung has to fish is the left side has one fissure sometimes. See an extra fissure in the right. Call the inside. This Fisher with an extra low. It's a normal variant we don't care about. We don't even report them anymore. Yeah, this is This is this is soft tissue density, and this is probably a tumor. This would need a CT scan. And if that's if that's not consolidation, and isn't that new thing is a bit weird suggest Oh, I think they should have had further imaging. Have they had a CT scan? And we might have to stand for you, which makes life a lot easier. I can't remember what these are now, so I'll put them together a while again. Okay, Now, if anyone can tell you what this is again very impressed. So we'll look at the we'll split the lungs again. Top middle bottom top looks fine. This is this funky first rib again. But yeah, you learned Just missed them. Middle zones like, Okay, this is emphysema, Doc. Remember, we said about emphysema and chronic lung changes and destruction of the lung tissue. That's that They were from the bottom. So we look at the long term look. Too bad. This this side looks very small compared to this size. I know your heart's in the way, but even so, it looks small to me. The left hemothorax has got the volume loss. Okay, They look at the heart shadow. The heart shadow looks okay. I've got out. Got out the ap MPA. Sorry. This is This is this is an A P, but the pa Sorry. So the heart size Okay. What's this here? This is very high density, isn't it? Is very, very high density. Almost up to metallic. It's not. It looks metallic. This is Has anyone come in to bring you up? It says by any chance, just shake your head or thumbs up or whatever. Uh, no. Someone just mentioned cardiomegaly Possibly Yeah, Okay. To be honest, I don't think there is cardiomegaly because they're very rotated to Here's the medial clavicle. and there is medial clavicle, so they're not quite there, not quite center. You can see the spinous processes going off this way rather than down the middle, so I think that they might have an element of it. But it's certainly not marked cardiomegaly. It's this year that I don't like. That is what we call the sale sign. So, like a sail and a yacht or a boat sailboat, whatever. And that is a left lower lobe collapse. So you get too hard, Borders. It looks like the heart doesn't It looks like the heart. And then you get the heart and you're like, Hang on a minute, you've got two hearts as the Grinch got to heart's, remember? But yeah, So basically, that is the sales time. It's the left lower lobe collapse. Any collapses. Unless you're an asthmatic and you frequently collapses like secretions and stuff, they have to have a CT that's usually an obstructing bronchial lesion was in that. Okay, so that's a sale sign. Um, again another one. This is an AP film. The heart's massive. You can't tell having it. It's just it's just huge tops. Fine Middle's fine bottom. Where is the bottom of the left of the right. Where is the right one? Where's it gone? And then we look at our animals now, unfortunately, chopped off. But the angle on this and the angles of the diaphragm and the ribs spot on, there's nothing there. It is spot on. You have to trust me. I'll show you later on. This is not spot on. So let's look, look how high the left hemidiaphragm is. It shouldn't be high. It should be lower than the left, no higher than the right height on the left. But it shouldn't be that high. And if you look it should, the diaphragm should go down here. This is very high density stuff down here, and it's kind of sweeping upwards. So you're losing that nice down with animal. It's going up again. What's that all about? So that is what we call meniscus. Like a fluid level that is a that's a good going right side of the fusion. Okay, so very high, then to see they tend to be, they tend to, and sometimes you see them right to the top of the lungs, and it's called a white out because it's so want. Okay, this is a bit more tricky. This is if you can pick this one up, have my job. I've chopped off the left hand side. Basically relevant. You should see this is the abnormalities. Your eyes will be into the drawn That is not right. Right? Upper zone. Look at the difference between the left hand, the thorax and the right hemithorax. You should always see more right hemithorax and left because there's no heart on the right, the next three extra party person, which they did put in my finals, which really confused. And, um, this is a right upper zone collapse. So volume loss and there's an s shape. Can you make that out backward? S. So from the top of the of the aerated lung down to the highland into the middle of the chest into the mediastinum. So it's called what we call the Golden s. Now that is cancer. That is, that is an obstructing right side and bronchialis. And I've never, ever seen it not be a cancer. Okay, so that needs CT scan. Damn long referral, blah, blah, blah. Um, that's bad. That's bad. That's yeah, that's cool. And if you do see them about an obligation, but for basically, it's a coupon, so we'll go on just a minute. But we don't. You know, lungs are really important. Of course they are. But you know, most conditions can tell you. Oh, there's a pneumothorax. It is big enough. You know, most people can have a good going extra my job to tell you the things that you're not going to see. Um, so let's look at the two. Your eyes should instantly be drawn to the left of reserve. There's something not right going on here. I think you agree. So the apex is. I'll go through the review areas that apex is very important for the review area because, like I say, it's quite crowded and there's a type of tumor grows in the apex, the lungs and it can cause all sorts of weird symptoms, including recurrent laryngeal nerve palsy, and it can make you a horse. So I know what to call it in the comments Common exam question, actually, So do you know what? Remember that one. So we're looking at the long so we know there's something going on up here I don't like that at all. Look at the density, this one compared to this one. This has got soft tissue density here. I don't like that. I think there's going to be a malignancy up here. Then we're going to look at the middle zone, find the lower zones are fine. There's a bit of lumping of this animal here, so look at the right. Lovely crisp. A nice, almost like a like a Nike side. Almost. You're not getting that on this side. Just like to start swoop again, isn't there? I think there's an infusion that left hand side along with this is now making me think. Hang on. There's a malignancy here. There's a malignant effusion with the soft tissue density. Look at the topicals. Look at the right clavicle. Beautiful. Beautiful, uh, angle amount. Uh, tropical with the manubrium. Where is the left? Just Republican. Well, no, that has been eroded away. That tumor tumor has actually eroded that bone away. So this person is in trouble. Not only have they got a primary malignancy also, if you look at the ribs, that first room completely eroded them, erode through the 1st, 2nd and 3rd anterior ribs. Not good. This person's in trouble. They've got to possibly even got in. They got into the transverse processes. Five. Probably not, But yeah, they're in trouble, aren't they? Got a little confusion. They've got soft tissue density and they've got bony destruction. They're going to be in trouble. And let's look at this AP window. So you've got aorta from the vasculature. This should be completely empty. Something in there. They've got massive lymphangiography as well. So this this person's big trouble. So this is the thing. I love this picture. Don't forget about the bones. They are there. They are difficult to interpret. I agree. Don't forget them. It's really hard to see what's not there. That sounds so stupid. You look at something, you go. Yeah, it's normal pool. You look at something, it's not there. I reported the scan and a CT scan of the day on call, and I I sent it off to the clinician's and I thought, Oh, I'll just double check some things I remember if I had written, it was a nodule or something, and I was like, Where's the humor restaurant? I just I I had no humorous because, like this in the scanner and the right. The left humerus was fine. The right humerus, it's gone. I was like, Where is it gone wrong? And he referred it, and I said I had broken his arm was like, No, I said Just x ray it. And he had completely stopped his arm in half because of the because the this language was so far away on its job. Checked it so you don't know what's not there, so you always have to check your bones carefully. Remember that bone disease? We're looking for lack of bone like the last one. It's gone. We're looking for fractures, looking for old fractures, fractures in the chest. X ray is really difficult stick unless the bones are literally like hanging off, you know, So displaced. Um, look for sclerosis as well. You know, you've got prostatic can turn. You get sclerosis. So very bright. Better bones, not normal. Always compared to the rest of the bones basically, and look for things like fractures like humorous look. The lytic lesions look for areas of low density of the bone. Quite common again. Common. The patient comes in to see a GP with a chronic cough, and we find a primary bone tumor, the lungs all the time. Uh, this, uh, you should be there. Never. That's obvious. But this is a nice anterior rib fracture. One to get knocked off three anterior ribs. Probably got posterior ribs as well. That's a big trauma. That And if you look down here, you've lost that nice costophrenic angle again. It's all the blood and go down there. Okay. So really anxious. Um, cardiac. Someone said so. Someone says cardiomegaly before. So the normal heart size is should be to imagine from here the right ventricle to the left ventricle. And then you measure from each side of the chest wall and the ratio of the cardiac to the thoracic should be less than 50%. Okay. On our workstations, it does it forward. It's great. Most people go like that, and that's the heart. Faster lungs. Massive. Um, we measure this if it's in pa. Remember, You often get a bit of high density down here. The patient is quite fat. You get a big, fat, pericardial fat pad, so don't confuse it with consolidation or anything. Look down here. I don't know what these might be and this So I'm going to tell your hands on my hands on my heart no pun intended. I can never remember which valves they are. This is This is a replacement valve I'd have to do. I have to Google every time. I can never remember which ones which one X ray. These are sternotomy wires. Patients had open heart surgery. Basically, So we know his heart is not ideal. Her heart apologies. Her heart is not ideal and she's had surgery. She's got a lot about it. It's probably the aortic valve, actually. And so we know she's probably going to have a big, massive heart, isn't she? If you have a big, massive heart, we look things like from the edema, so I'll show you a picture of edema. But we can look for bilateral fusions that's got that's got the left right side of refuge in the left. Okay, we also look at the upper lobe diversion. So where these vessels are here, sometimes they're very prominent. The lower ones should be more prominent on the upper ones, and the other ones are more prominent to kind of kind of chronic heart. Very important in my attention. What am I trying to show you? This one? Oh, yeah. Massive heart. You can just eyeball it and you go. Oh, yeah. Massive. That's huge. So yeah, that's cardiomegaly. This is Paula Deen. So this is so I'm sure you've all seen X rays are coded the horrendous are they? Very patchy. Patchy what we call patchy infiltrates everywhere, but mainly in the periphery. It belongs. This is very central. Lots of increased density around the hilum. And it's very central along with a huge heart. Pulmonary edema. Okay, we'll put your diaphragm. Comes right to the hives on the left. Not right yet. Look out the air with the diet front area under the diaphragm on the right chest. X ray is a perforation in the abdomen. Until proven otherwise, it's always a perforation or post surgery. Yeah, but post surgery, checking costophrenic angles and your cardiogram that handles as well for any of using. This is a perforation. So this is a row of the diaphragm. Difficult on the left, sometimes with the gastric bubble. So the stomach usually has Aaron it. So be a little bit careful on this left and the right hand side. There's a big this patient's perfect of the bowel, something very quickly review areas. These are things happening with this long agencies Bang my about that Those I have missed something in the lung agencies. I'm listening with all rats because there's just so much no excuses that. But I did. So I bang on about it a lot. Now, behind the heart, you can have consolidation. You can have tumors. You can have madness behind the heart. Check their diaphragm is difficult, you know, give it a good look Really peripheries. We all forget the referees of the lung, and you can get little pleural based tumors like the Steelers and things like that the highland you have to get. You have to get your eye into the highland. You, when you first start up on X rays, are reporting them or telling people about them. You always say all the highland, what's really, really bulky probably isn't. Um some people say you need this island. When we widened, I would personally say genuinely. Now what? I've been told this a few times in my previous years. If you're not a radiologist, do not comment on the media silent so variable you can have someone who are completely normal. Very skinny person. Have a massive mediastinum very variable. So don't mention it is to get yourself into trouble. And that's not asking things about Oh, what does that mean? Like behind the breast shadows when they've got breast implants? Very difficult. So quick. Feel of a few of these just because it's just to show you there are new areas. Really? Um, if I can remember about myself, um, I think I can see it. I think so. This is a P. O S, A. P film. How much The scapula there in the way. They're basically covering half the lungs aren't there. It's not ideal. They're not reading that much. But for this, So the left heart, isn't it? It's the left heart border. You should be able to die from the hallway to the left heart border. Something behind that part. It's either infection or it's a tumor. We need to really like, you know, you ask the clinician's what do you think's going on rather than inflammatory markers doing blah, blah, blah. So that's that, Um, hold this. Now, this this is, um what is that. Actually, that's probably some tubing of some description for probably some oxygen that's been like chilling on her abdomen rather than in the nose Racial thing. This here is a lot of agencies. Can you can you make out these little tiny vessels up here? Where is this? There's no vessels. And you see this line here? This is this is the long border. So this is a pneumothorax. And honestly, they can be so much more support that what is this account? And then, um, there's an awful picture. Um What I said this is Oh, yeah. Look at the highland compared to this island. Grandkids, they are rotated. I agree. But look how bulky that is. That's not right. That's not right at all. That's probably massive. We definitely do not think so. There's there's something going on there. This is similar to the one I showed you earlier. So what I told you about earlier, you know, with all the really bad picture looked awful and that loads of spot sort of a Dalmatian, the cannonball metastases. And they are from renal cell carcinoma. That dot com is a question. There is the primary tumor. There and there's multiple soft tissue nodule everywhere, but actually there, there, there, there, there, there, there. There's one just here. Can you see that? So this is under the diaphragm behind the heart, and there's one here as well. This is what I mean about the diaphragm. Was one there that might be That might be an inclusion. So if you miss it, the patient's going to go home from the from the next. I'm going to come back like this for the for the cancer. That's what everyone. That's all I've got for you. Um, any questions? There's the references are no abdominal should be checked. Any questions at all? Any questions Wednesday? Uh, not so far, but I think usually lax to let you know, found that Easter There's one. So far, it says this light with the left side of pneumothorax. What was happening at the lower zone of the right lung? Same 2. 15. There was in the right lung down here. Um, probably to be fair, probably a little bit of the level before that electrolysis. So you can't quite tell um, the left because the heart's in a way, you can still see the diaphragm can't quite see what's going on here. I agree. It's a bit stuffy down there. Your office, The report saying more was atelectasis at a Lexus is basically a bit of like long tissue rather than being a rated squished. So it looks a little bit like a little line. Or was it fluffy? If it's not consolidated, I don't You think that's a consolidation? It's not. It's not quite discrete enough consolidation. It's very odd place for it to be. It's going to be consolidated. It's usually going to be low bar. I meant to tell you, actually, um, they love it when we tell them where the consolidation is. If it's just kind of patchy, is difficult, like over the carbon tell it's everywhere. Um, if something is obscuring. But this let this right heart border. So if you've got like this here this little fluffy bit, if you've got this up here, it's just remember if it's obscuring the right heart border, it's in the right middle zone. Know right middle lobe. Okay, remember that, for example, if it's obscuring the left heart, border is probably in the lingular to the little extra bit of flaps on top of the left lung. Uh, sorry. Somebody mentioned that it wasn't that particular slide. I think it's earlier. One for pneumothorax. I mean, it's all right that one morning. Now the lung collapse. This one here, what's going on down here is absolutely nothing. It's the breast. Here's the breast. This is what I mean. You say about to the image the three d person. Um, so they're quite skinny, which helps, but they've got quite dense breast, actually. Can't really see on the left hand side because of the thorax is ruined. Everything. If you look on this right side here, look at the breast tissue. This is actually breast tissue, but again, it's superimposed. This is normal longer underneath it. And this is normal disc. A long time. Remember, I always think of the long anatomy, the zones and the different, like the different loads on on my record sagittal view. So through the central like this way, um, this is the lower lobe actually goes really far, far back, and there's no point listening. You're examining clinically the lower long the the right on the left lower lobe. Anterior, You're not going to hear you listen to the back. You're not going to hear five AIDS or preps. You're not going to hear the front because it's not the base. So that is actually normal. A rate along here. It's just because the Brexit you spread out, um, somebody's ask. Is there any difference between X ray appearance of consolidation and long infiltrates? It is interchangeable, so long infiltrates is usually like infiltrative change. Some people say consolidation because consolidation is pneumonia, isn't it? So you can't diagnose pneumonia? It's a radiological diagnosis. Um, so it's a It's a lower respiratory tract infection with X ray changes. Long infiltrates tend to be things like You can have infiltrated changes you can have like, um, things like Easy is eosinophilia that's like ulcerative. That's usually I don't know if you remember. Like, if I'm doing the secondary pulmonary lobule you guys remember, that is when you have, like a hexagonal, um, long like doing like herself to have, like, a hexagonal area, and you've got your your bronchi vessels. Then in between each like each hexagonal bit, which is your elbow live. Essentially, that's where your infiltrates live. So that's why we get bronchogram because we get all cracked inside the lungs like Duncan. You know, you get all that in those spaces, and that's why it looks so you get the air through it and some consolidation and infiltration. Some people don't quite want to call consolidation. If it's not that dense. If it's just a little bit patchy, you're not quite sure you call it a pill. It's a bit like sit on the fence you don't want to. You don't want to call it pneumonia because it's not that bad. But it's definitely something there. One more question. Helping precisely differentiate between consolidation and effusion on chest X ray. Besides the meniscus, um, the density. So it's usually that is usually more dense if it's an infusion, if it's an infusion, it's 99% 90 10 times in a box in the lungs. Um, so you're going to lose it from spreading angles. However, it could be a loculated infusion or empyema. Now that's that can be You can have an infusion. I think they're like up here. I have one meal a day, and it kind of went up here and then here and then here, and then here it looks really odd. Um, so it almost looked like light. Sensitive, easily over like a pleural, um, soft tissue. Think it was very odd, but that could be a loculated one consolidations. All are wrong program since all. Yeah, So, uh, right. Where is that? The usual one. Uh, if you're looking at right, this consolidation, this is really dense hitting you in the face. It's in a low bar distribution. You cannot see that right heart board. You see the bottom of it you can't quite see. That is right. Middle lobe consolidation. If you look, you can't really see, that's the problem. That's why you can't really see the right main bronchus. You can see the area where you see it in here and you can follow. If you look really closely, you can follow the airways, right the way to the periphery. So there's crap in the lungs. It's not in the Broncos. It's in the long parent kindness in the intersection of the lung. Um, so we get a wrong program, so it's a rare within, but within the lungs, all that air on the ground. You don't get that with the fusion because the fusion is in the pleural space in the potential space. That's not a space. There was fluid in the wrong place. Okay, Another question. How would you know an act? Alexis's is caused by airway obstruction or pneumothorax that Alexis usually secondary to squishing of some prescription or scarring. So if you've had a nasty chest infection with the middle consolidation, usually the lower load you'll get a little you'll get, like, a little line of like, a like a little band of white. Um, it's usually secondary to previous infection it could be down to. So sometimes you've got an infusion. And where the infusion is actually pushed the lung tissue together to punch it up a bit. That can that can, cause that can cause anaphylaxis. Um, post surgery. They get athletic as far as they're not breathing properly. And if you're in pain or they've got a problem when they're in pain, I'm not breathing properly. So they're not standing alone, so they get squishing at the bottom. Um, I can't answer that. Um, there is another question, um, was done by particular nodule. Er pattern, uh, is that an infiltrate? Give the same appearance? Yes, a particular it's really difficult to show you because it's the image quality. When I inject it and then share. It's great on Microsoft. It's basically so particular around. I'm not a killer. So in particular is like lines and nodular was like a nodule. Circle things so particular nodule. A picture is usually an infiltrate services, so it's not quite consolidation just yet. It's in a long in decision, and you get a larger pattern with lots of different diseases. So, like I think cryptococcus disease or caucus infection along here, particularly larger shadowing, Um, like it's just a certain descriptive term, really, and it's usually usually use more N. C T. We can see more. So like the TV, for instance, there's a tree and but literally looks like a tree and those little like blossoms on the end. And that's typical finding for TB infection in the lungs. So it's just like just like a weight. It's like it's like a descriptive term, really, for what is going on in the lungs. It's all usually a an effective thing. Sometimes you'll see, like here, so the next one, this here and this and this see a very high density compared to the best rounded thing. Now we're all in the past to call them little tumors or cancers. That modules, they're actually vessels coming towards you and see if we can If there's not a lot of them all by the highland, usually bilateral and there's nothing else the lung, the lungs are completely clear. Otherwise, probably vessel we've all over called those. We've all set up the CT. The CT scan was fine. Just going to give them a couple of seconds more to see them anymore. Well, we can look in a second. Just remember, if anybody asks you for a check A chest X ray for mg feeding if you're not sure, don't target. So you can't like you really can't like it. If you're not sure you know who eats. Remember the night. No one, you know, 99% of time the patient actually can wait or get senior to have a little look or in the radiology edge. You know, we don't mind. It's a 32nd job for us. Um, please don't like it. A lot of hospitals now have, like, certain, have to do certain like we have to do, even if you just got to do it. Last year we had to do a course of like a module. And if you pass that, you're allowed to be allowed to say so yes or no feeding. And if you didn't, you weren't allowed allowed to interpret them. Fair enough. Really? So please don't like it. It's not worth your your life seats. I don't think there's any questions so far that everyone who everyone says thank you for the presentation. It's really good, don't you? The QR code. But if you want to pop that on your screen, uh, let me just stop sharing for a minute and then very clearly what age and on the chat. Oh, to offered stupid? Yes. Oh, no need for QR code. Okay. Who again? No more questions. Thank you very much for listening. Everyone really appreciate it. Hope it Hope it hope is useful. At least at least take one thing or two things or even that's great. Please fill in. Please fill in the feedback forms